Epidemiology and outcomes of infections during extracorporeal membrane oxygenation in adult patients with COVID-19 ARDS- A single center study

BACKGROUND

There is a scarcity of data regarding nosocomial infections in patients with COVID-19 treated with ECMO. This observational study from India aims to describe the epidemiology and microbiology of infections in patients with COVID-19 associated ECMO.

METHODS

This is an ambi-directional observational study of COVID-19 ECMO patients admitted from April 2021 to June 2022 in a tertiary care hospital. The total number of sepsis episodes for each patient was recorded and were categorized as bloodstream infections (BSI), pneumonias, skin and soft tissue infections (SSTI), invasive candidiasis (IC), catheter associated urinary tract infection (CAUTI), intra-abdominal infections (IAI), and Clostridioides difficile infections. Details regarding each infection including the microbiological profile and outcomes were recorded.

RESULTS

29 patients who received ECMO for COVID-19 pneumonia during the study period were identified. Of the 29 patients, there were a total of 185 septic episodes. The incidence of septic episodes was 72.4 per 1000 ECMO days. Of the 185 sepsis events, 82 (44.3%) were BSI, 72 (39%) were pneumonia, 19 (10.3%) were SSTI, 7 (3.8%) were CAUTI and 5 (2.7%) were IAIs. Of these 29 patients, 16 (55.2%) patients were discharged and 13 (44.8%) died.

CONCLUSIONS

The most common infections in our patients were bloodstream infections followed by pneumonia. High rates of gram negative infections, including those caused by carbapenem resistant bacteria, reflect the Indian critical care unit epidemiology in general. Despite these high infection rates with antimicrobial resistant set of micro-organisms, we had a successful outcome in 55.2% of patients.

Xpert Carba-R Assay on Flagged Blood Culture Samples: Clinical Utility in Intensive Care Unit Patients with Bacteremia Caused by Enterobacteriaceae

Introduction and background

Rapid molecular diagnostics to predict carbapenem resistance well before the availability of routine drug sensitivity testing (DST) can serve as an antimicrobial stewardship tool in the context of high rates of Carbapenem-resistant Enterobacteriaceae (CRE).

Materials and methods

A retrospective observational study of patients more than 18 years of age on whom Xpert Carba-R (FDA approved for rectal swab specimen) was done on gram-negative bacteria (GNB) flagged blood culture samples, in an Indian intensive care unit between January 2015 and November 2018. We analyzed the performance of Xpert Carba-R in comparison with routine DST.

Results

A total of 164 GNBs were isolated from 160 patients. Klebsiella pneumoniae and Escherichia coli were the predominant isolates. Carba-R was positive in 35.36% of samples and 45.34% were carbapenem-resistant (CR) on routine DST. The distribution of the CR gene was: Oxacillinase (OXA) (50%), NDM (32.7%) followed by OXA and NDM co-expression (15.51%). The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, and negative predictive value of Carba-R were 90.74, 93.15, 13.25, 0.10, 83.58 and 96.31% for Enterobacteriaceae. The median time to obtain the Carba-R report was 30 hours 34 minutes vs 74 hours and 20 minutes for routine DST. Based on the Carba-R report, 9.72% of patients had escalation and 27.08% had de-escalation of antibiotics.

Conclusion

Xpert Carba-R serves as a rapid diagnostic tool for predicting carbapenem resistance in intensive care unit patients with bacteremia caused by Enterobacteriaceae.

How to cite this article

Rajendran S, Gopalakrishnan R, Tarigopula A, Kumar DS, Nambi PS, Sethuraman N, et al. Xpert Carba-R Assay on Flagged Blood Culture Samples: Clinical Utility in Intensive Care Unit Patients with Bacteremia Caused by Enterobacteriaceae. Indian J Crit Care Med 2023;27(9):655-662.

Proceedings of the expert consensus group meeting on herpes zoster disease burden and prevention in India: An opinion paper

Herpes zoster (HZ) is a debilitating viral infection causing a dermatomal vesicular rash. Many known risk factors exist in India and adults >50 years of age may be especially susceptible to HZ. However, HZ is not a notifiable disease in India and data on incidence and disease burden is lacking. An Expert Consensus Group meeting was conducted with experts from relevant specialties to discuss HZ disease, its local epidemiology, and suggestions for implementing HZ vaccination in the Indian healthcare system. Currently, there is lack of patient awareness, poor reporting practices and general negligence in the treatment of the disease. HZ patients generally approach their general physicians or specialists for diagnosis, which is usually based on patient history and clinical symptoms. Recombinant zoster vaccine (RZV) has >90% efficacy and is recommended in adults ≥50 years of age to prevent HZ in the United States. Despite RZV being approved for use, it is not yet available in India. India has a growing elderly population with known risk factors for HZ like immunosuppression, and co-morbidities like diabetes and cardiovascular disease. This indicates the need for a targeted immunization program in India. Meeting also emphasized adult vaccine availability and accessibility in the country.

Myopia Control Dose Delivered to Treated Eyes by a Dual-focus Myopia-control Contact Lens

PURPOSE

This study examined the optical impact of a DF contact lens during near viewing in a sample of habitual DF lens wearing children.

METHODS

Seventeen myopic children aged 14 to 18 years who had completed 3 or 6 years of treatment with a DF contact lens (MiSight 1 Day; CooperVision, Inc., San Ramon, CA) were recruited and fit bilaterally with the DF and a single-vision (Proclear 1 Day; CooperVision, Inc.) contact lens. Right eye wavefronts were measured using a pyramidal aberrometer (Osiris; CSO, Florence, Italy) while children accommodated binocularly to high-contrast letter stimuli at five target vergences. Wavefront error data were used to compute pupil maps of refractive state.

RESULTS

During near viewing, children wearing single-vision lenses accommodated on average to achieve approximate focus in the pupil center but, because of combined accommodative lag and negative spherical aberration, experienced up to 2.00 D of hyperopic defocus in the pupil margins. With DF lenses, children accommodated similarly achieving approximate focus in the pupil center. When viewing three near distances (0.48, 0.31, and 0.23 m), the added +2.00 D within the DF lens treatment optics shifted the mean defocus from +0.75 to -1.00 D. The DF lens reduced the percentage of hyperopic defocus (≥+0.75 D) in the retinal image from 52 to 25% over these target distances, leading to an increase in myopic defocus (≤-0.50 D) from 17 to 42%.

CONCLUSIONS

The DF contact lens did not alter the accommodative behavior of children. The treatment optics introduced myopic defocus and decreased the amount of hyperopically defocused light in the retinal image.

Hospital-based antimicrobial stewardship, India

Objective

To establish a framework for implementing antimicrobial stewardship in Indian tertiary care hospitals, and identify challenges and enablers for implementation.

Methods

Over 2018-2021 the Indian Council of Medical Research followed a systematic approach to establish a framework for implementation of antimicrobial stewardship in Indian hospitals. We selected 20 Indian tertiary care hospitals to study the feasibility of implementing a stewardship programme. Based on a questionnaire to lead physicians before and after the intervention, we assessed progress using a set of process and outcome indicators. In a qualitative survey we identified enablers and barriers to implementation of antimicrobial stewardship.

Findings

We found an improvement in various antimicrobial stewardship implementation indicators in the hospitals after the intervention. All 20 hospitals conducted monthly point prevalence analysis of cultures compared with three hospitals before the intervention. The number of hospitals that initiated formulary restrictions increased from two to 12 hospitals and the number of hospitals that started practising prescription audit and feedback increased from six to 16 hospitals. Respondents in 15 hospitals expressed their willingness to expand the coverage of antimicrobial stewardship implementation to other wards and intensive care units. Six hospitals were willing to recruit the permanent staff needed for antimicrobial stewardship activities.

Conclusion

Antimicrobial stewardship can be implemented in Indian tertiary hospitals with reasonable success, subject to institutional support, availability of trained manpower and willingness of hospitals to support antimicrobial stewardship-related educational and training activities.

Post-COVID multisystem inflammatory syndrome in adults: a study from a tertiary care hospital in south India

Background & objectives

There are limited data from India on the post-COVID multisystem inflammatory syndrome in adults (MIS-A). The objective of the present study was to evaluate the clinical profile of patients with MIS-A admitted to a tertiary care centre in southern India.

Methods

This single-centre retrospective study was conducted from November 2020 to July 2021, and included patients aged >18 yr admitted to the hospital as per the inclusion and exclusion criteria.

Results

Nine patients (5 male, mean age 40±13 yr) met the criteria for MIS-A. Five patients had proven COVID-19 infection or contact history 36.8±11.8 days back. All patients were positive for SARS-CoV-2 IgG antibody, negative for COVID-19 PCR, and had negative blood, urine and sputum cultures. All patients had fever and gastrointestinal (GI) symptoms, and five patients had left ventricular dysfunction. All patients had neutrophilic leucocytosis at presentation and elevated biomarkers such as C-reactive protein serum procalcitonin, D-dimer and ferritin. The majority of the patients (7/9 i.e. 77.78%) were treated with intravenous hydrocortisone (50-100 mg q6h-q8h). Six patients recovered completely whereas three patients expired.

Interpretation & conclusions

Fever and GI symptoms were the most common presentation of MIS-A. Elevated serum procalcitonin may not be useful in differentiating bacterial sepsis from MIS-A. Most patients responded to corticosteroids.

Dietary Effect of Padina boergesenii on Growth, Immune Response, and Disease Resistance Against Pseudomonas aeruginosa in Cirrhinus mrigala

In the aquatic environment, seaweeds have the potential to be renewable resources. The current study was designed to assess the impact of seaweed Padina boergesenii incorporated into a basal diet at various concentrations. The phytoconstituents of the seaweeds were characterised by gas chromatography-mass spectrometry. Diets were designed to include elevated levels of 0.5%, 2.5%, 4.5%, and 6.5% of seaweed meal. Significant differences in Cirrhinus mrigala fed with P. boergesenii incorporated into the basal diet for 45 days. The growth parameters (weight gain, specific growth rate), biochemical constituents, and immunological assays were observed. The extract fraction demonstrated effective inhibitory activity against Pseudomonas aeruginosa. As a result, this research suggests that extracts of the seaweed P. boergesenii contain potential bioactive compounds with significant antibiotic activity.

Infections caused by Aeromonas species in hospitalized patients: A case series

The Aeromonads are ubiquitous Gram-negative bacilli that cause community acquired, and healthcare associated infections. In this retrospective study we analysed clinical and microbiological characteristics of thirty-six culture proven Aeromonas infections. The most common species isolated was A.hydrophila. Clinical presentation included syndromes like skin and soft tissue infections (SSTI), urinary tract infections, and central line associated bloodstream infections (CLABSI). Most of the isolates were sensitive to aminoglycosides [97.2%], followed by 3 rd generation cephalosporins, quinolones and carbapenems. Overall mortality was 13.88% (5 out of 36 patients). A high index of suspicion is required for diagnosis and better outcomes.

Approaches for Multilingual Phone Recognition in Code-switched and Non-code-switched Scenarios Using Indian Languages

In this study, we evaluate and compare two different approaches for multilingual phone recognition in code-switched and non-code-switched scenarios. First approach is a front-end Language Identification (LID)-switched to a monolingual phone recognizer (LID-Mono), trained individually on each of the languages present in multilingual dataset. In the second approach, a common multilingual phone-set derived from the International Phonetic Alphabet (IPA) transcription of the multilingual dataset is used to develop a Multilingual Phone Recognition System (Multi-PRS). The bilingual code-switching experiments are conducted using Kannada and Urdu languages. In the first approach, LID is performed using the state-of-the-art i-vectors. Both monolingual and multilingual phone recognition systems are trained using Deep Neural Networks. The performance of LID-Mono and Multi-PRS approaches are compared and analysed in detail. It is found that the performance of Multi-PRS approach is superior compared to more conventional LID-Mono approach in both code-switched and non-code-switched scenarios. For code-switched speech, the effect of length of segments (that are used to perform LID) on the performance of LID-Mono system is studied by varying the window size from 500 ms to 5.0 s, and full utterance. The LID-Mono approach heavily depends on the accuracy of the LID system and the LID errors cannot be recovered. But, the Multi-PRS system by virtue of not having to do a front-end LID switching and designed based on the common multilingual phone-set derived from several languages, is not constrained by the accuracy of the LID system, and hence performs effectively on code-switched and non-code-switched speech, offering low Phone Error Rates than the LID-Mono system.

Clinical Profile of Non-neutropenic Patients with Invasive Candidiasis: A Retrospective Study in a Tertiary Care Center

Introduction: Invasive candidiasis (IC) is a major cause of morbidity and mortality in critically ill patients in the intensive care unit (ICU). In this study, we aim to analyze the clinical profile, species distribution, and susceptibility pattern of patients with IC. Methods: Case records of non-neutropenic patients ≥18 years of age with IC between January 2016 and June 2019 at a tertiary care referral hospital were analyzed. IC was defined as either candidemia or isolation of Candida species from a sterile site (such as CSF; ascitic, pleural, or pericardial fluid; or pus or tissue from an intraoperative sample) in a patient with clinical signs and symptoms of infection. Results: A total of 114 patients were analyzed, out of which 105 (92.1%) patients had bloodstream infection (BSI) due to Candida and 9 (7.9%) had IC identified from a sterile site. Central line-associated blood stream infection (27 patients, 23.6%) and a gastrointestinal source (30 patients, 26.3%) were the most common presumed sources for candidemia. The commonest species was Candida tropicalis 42 (36.8%), followed by Candida glabrata 20 (17.5%). Serum beta-D-glucan (BDG) was done only in 32 patients of the 114 (35.3%); among those who were tested, 5 (15.6%) had a BDG value of less than 80 pg/mL despite having Candida BSI. Fluconazole sensitivity was 69.5% overall. At 14 days after diagnosis of IC, 49.1% had recovered, with the remainder having an unfavorable outcome (32.4% had died and 18.4% had left against medical advice). Clinical significance: IC is a major concern in Indian ICUs, with a satisfactory outcome in only half of our patients. Serum BDG is a valuable test to diagnose blood culture-negative IC, but more studies are needed to determine its role in the exclusion of IC, as we had a small minority of patients with negative tests despite proven IC. Conclusion: We recommend sending two sets of blood cultures and serum BDG assay for all suspected patients. Initiating empiric antifungal therapy with an echinocandin is advisable, in view of increasing azole resistance and the emergence of Candida auris, with de-escalation to fluconazole for sensitive isolates after clinical stability and blood culture clearance. How to cite this article: Sridharan S, Gopalakrishnan R, Nambi PS, Kumar S, Sethuraman N, Ramasubramanian V. Indian J Crit Care Med 2021;25(3):267-272.

A technique for quantifying the sensitivity of dosimetric tool gamma with 2D detector array in pretreatment IMRT plans by segment deletion method

OBJECTIVES

Motivation of this study is to check the sensitivity of dosimetric tool gamma with 2D detector array combination when unexpected errors occur while transferring intensity-modulated radiation therapy treatment plans from planning system to treatment unit.

METHODS

This study consists of 17 head and neck cancer patient's treatment plans. Nine types of verification plans are created for all 17 clinically approved treatment plans by consecutively deleting different segments (up to eight) one by one from each field of the plan. Decrement factor (χ) is introduced in our study which illustrated the degree of decay of gamma passing rate when intentional errors are introduced. We analyzed the data by two different methods-one without selecting the region of interest (ROI) in dose distributions and the other by selecting the region of interest.

RESULTS

By linear regression, the absolute value of slopes is 0.025, 0.024 and 0.015 without ROI and 0.030, 0.027 and 0.015 with ROI for 2%/2 mm, 3%/3 mm and 5%/5 mm criteria, respectively. The higher absolute value of the fitted slope indicates the higher sensitivity of this method to identify erroneous plan in treatment unit. The threshold value for 2%/2 mm equivalent to 95% passing criteria in 3%/3 mm used in clinical practice is obtained as 83.44%.

CONCLUSIONS

The 2D detector array with dosimetric tool gamma is less sensitive in detecting errors when unprecedented errors of segment deletion occur within the treatment plans.

Experimental Model of Far Temporal Field Negative Dysphotopsia Generated in Phakic Eyes

Purpose

The axial separation between the iris and the intraocular lens (IOL) in pseudophakic eyes can cause rays originating from the far temporal field to miss the IOL, resulting in negative dysphotopsia (ND). We developed an experimental model to test the hypothesis that obstruction of rays from the far temporal field can generate ND and an accompanying loss of visual sensitivity in the far temporal field.

Methods

The right eyes of 10 phakic subjects were fitted with soft contact lenses containing a 5.50-mm central clear zone and a 12-mm outer diameter opaque annulus. In three of the subjects, eyes were dilated with 1% tropicamide solution, and effective aperture diameters were determined optically (pupil camera) and psychophysically (narrow beam detection). Visual field extent (Goldmann bowl) and temporal and inferotemporal meridian sensitivities (Octopus perimeter) were measured. A wide-angle model was constructed to quantify the impact of the annular opacity on retinal illuminance.

Results

All 10 subjects observed a dark crescent in the far temporal and inferotemporal fields. The opaque annulus reduced effective horizontal pupil diameters from 8 mm to 5.5 mm on-axis and from >2 mm to <1 mm at 90°. Perimetry revealed a 10° reduction in temporal and inferotemporal field extent and increasing loss of sensitivity beyond 70°. The wide-angle model confirmed significant vignetting (>50% beyond 70°), approaching zero retinal illuminance beyond 85°.

Conclusions

Vignetting of rays originating from the far temporal field by axially separated apertures can create symptoms mirroring perceptual reports of negative dysphotopsia in symptomatic pseudophakic patients.

Talaromyces marneffei Outside Endemic Areas in India: an Emerging Infection with Atypical Clinical Presentations and Review of Published Reports from India

Talaromycosis is a disseminated disease caused by Talaromyces (Penicillium) marneffei, mainly seen in acquired immunodeficiency syndrome (AIDS) patients. Its distribution is restricted to southeast Asian countries; a small pocket of endemicity exists in the northeast Indian state of Manipur. Here, we present a series of five cases presenting to our tertiary care hospital, originating from non-endemic states neighboring Manipur. In addition to the geographical distinction, a variety of unique features were noted in our cases, including human immunodeficiency virus (HIV)-negative hosts, the absence of typical skin lesions, presentation as pneumonia and generalized lymphadenopathy. Our series highlights the importance of distinguishing this disease from histoplasmosis and tuberculosis, both endemic in India.

Policy document on antimicrobial stewardship practices in India

Antimicrobial resistance (AMR) in India has become a great threat because of high rate of infectious diseases. One of the key contributing factors is high antibiotic use due to poor prescription practices, self-medication, over-the-counter sale of drugs and lack of awareness. Antimicrobial stewardship programme (AMSP) have been proved to be successful in restraining sale and use of antibiotics to a large extent in many countries. An AMSP programme for a hospital is imperative for rational and evidence-based antimicrobial therapy. The ultimate aim is to improve patient outcomes, reduce emergence of bacterial resistance and ensure longevity of the existing antimicrobials. The primary goal of AMSP is to encourage cautious use of available antibiotics by training the healthcare workers and creating awareness. This article describes the strategies and recommendations for formulation of AMSP policy for India.

Variations in antibiotic use across India: multi-centre study through Global Point Prevalence survey

The aim of the study was to assess antimicrobial prescribing patterns, and variation in practice, in India. A point prevalence survey (PPS) was conducted in October to December 2017 in 16 tertiary care hospitals across India. The survey included all inpatients receiving an antimicrobial on the day of PPS and collected data were analysed using a web-based application of the University of Antwerp. In all, 1750 patients were surveyed, of whom 1005 were receiving a total of 1578 antimicrobials. Among the antimicrobials prescribed, 26.87% were for community-acquired infections; 19.20% for hospital-acquired infections; 17.24% for medical prophylaxis; 28.70% for surgical prophylaxis; and 7.99% for other or undetermined reasons. Antibiotic prescribing quality indicators, such as reason in notes and post-prescription review score, were low. This PPS showed widespread antibiotic usage, underlining the need for antibiotic stewardship to promote evidence-based practice.

Newer β-Lactam/β-Lactamase inhibitor for multidrug-resistant gram-negative infections: Challenges, implications and surveillance strategy for India

Antimicrobial resistance (AMR) is a major public health concern across the globe, and it is increasing at an alarming rate. Multiple classes of antimicrobials have been used for the treatment of infectious diseases. Rise in the AMR limits its use and hence the prerequisite for the newer agents to combat drug resistance. Among the infections caused by Gram-negative organisms, beta-lactams are one of the most commonly used agents. However, the presence of diverse beta-lactamases hinders its use for therapy. To overcome these enzymes, beta-lactamase inhibitors are being discovered. The aim of this document is to address the burden of AMR in India and interventions to fight against this battle. This document addresses and summarises the following: The current scenario of AMR in India (antimicrobial susceptibility, resistance mechanisms and molecular epidemiology of common pathogens); contentious issues in the use of beta-lactam/beta-lactamase inhibitor as an carbapenem sparing agent; role of newer beta-lactam/beta-lactamase inhibitor agents with its appropriateness to Indian scenario and; the Indian Council of Medical Research interventions to combat drug resistance in terms of surveillance and infection control as a national response to AMR. This document evidences the need for improved national surveillance system and country-specific newer agents to fight against the AMR.

396. Clinical Features of Proven and Probable Cases of Histoplasmosis and the Role of Urinary Histoplasma Antigen Testing: A Case Series From India

Background

Histoplasmosis is considered uncommon in India, and the diagnosis usually depends on invasive tissue sampling. The histoplasma urinary antigen assay is a non-invasive test that has been recently introduced in India.

Methods

This was a single-centre retrospective study done from January 2013 till February 2018. Case records of patients with proven (confirmed by demonstrating intra-cellular yeast like organisms on histopathology or culture) and probable (presence of antigenuria—done by IMMY Alpha Histoplasma enzyme immunoassay) histoplasmosis were analysed.

Results

A total of 37 patients (18 proven and 19 probable) with mean age of 51.59 ± 11.17 years were studied. Diabetes was the most common co-morbidity (15 patients) followed by HIV (6), whereas no co-morbidity was found in 10 patients. Adrenals (29%), lungs (27%), lymph nodes (27%), and skin and oral mucosa (24.3%) were the most common organs involved (Figure 1). Anti-tubercular therapy based on granulomatous inflammation was given to 10 patients prior to the diagnosis. Raised GGTP and ALP (54%) and hyperglobulinemia (40%) were the common laboratory features. Most patients (83.7%) came from endemic areas (North-Eastern states, West Bengal, and Bangladesh) whereas all six cases from non-endemic areas were classified as probable (Figure 2). All-cause mortality rate was 10.8%, with 27 cases (72.9%) showing improvement at a median follow-up of 6 months. Comparison of proven and probable cases revealed that the following features were significantly higher in theprobable group: female sex (P = 0.001), coming from nonendemic areas (P = 0.009), requiring in-patient care (P = 0.001), leucocytosis (P = 0.043), absence of skin and oral mucosal findings (P = 0.002), simultaneous alternate diagnosis (P = 0.039), and death (P = 0.039).

Conclusion

This study emphasises that histoplasmosis is an under recognised entity in India. Histoplasma antigenuria does help in making the diagnosis easily and needs to be more extensively utilized by clinicians. However, it can yield false-positive results in patients belonging to nonendemic areas and lacking typical clinical features of histoplasmosis. Further studies are needed to determine the utility of the antigen test in Indian settings.

Disclosures

All authors: No reported disclosures.

Efficacy and Cost Comparison of Ertapenem as Outpatient Parenteral Antimicrobial Therapy in Acute Pyelonephritis due to Extended-spectrum Beta-lactamase-producing Enterobacteriaceae

Outpatient parenteral antimicrobial therapy (OPAT) programs are becoming an increasingly popular trend in clinical practice as they offer several benefits to both patients and health-care setups. While OPAT is an established clinical practice in the Western world, the concept itself is alien to patients in India as they prefer the security of hospitals to receive antibiotics over OPAT. We evaluated the clinical response and cost comparison of ertapenem under OPAT versus inpatient settings in patients with extended-spectrum beta-lactamase (ESBL)-positive acute pyelonephritis (APN) given the increasing importance of optimizing both hospital beds and overall cost of patient care in India. APN was chosen as the indication to be studied as it is one of the common complicated urinary tract infections treated in our OPAT unit requiring 10–14 days of parenteral therapy with an agent active against various Gram-negative bacilli and multidrug-resistant organisms. One hundred patients were retrospectively studied based on whether antibiotics were administered during hospital stay alone (hospital only), during both hospital stay, and also as OPAT post discharge (hospital/OPAT) or as OPAT alone (OPAT only). Response to ertapenem and cost of treatment in inpatient versus OPAT settings were compared using Pearson's Chi-square or Fisher's exact test for categorical variables. ANOVA (or Kruskal–Wallis) was used for continuous variables. Baseline urine cultures were ESBL positive with 98% prevalence of Gram-negative bacilli (GNB). Colony counts were ≥100,000 in 74% patients. Only ertapenem, imipenem, and meropenem showed 100% sensitivity to ESBL-positive GNB in baseline urine culture and sensitivity reports. Ertapenem showed 100% sensitivity and complete clinical resolution for 96% patients with APN due to ESBL Enterobacteriaceae. It was administered as OPAT in 90% patients and significantly reduced overall treatment costs.

Utility of multiplex polymerase chain reaction (PCR) in diarrhea-An Indian perspective

BACKGROUND

Infective diarrhea causes morbidity worldwide. Polymerase chain reaction (PCR)-based pathogen diagnostics of diarrheal stool specimens are shown to be highly sensitive and rapid as opposed to conventional diagnostics.

METHODS

We analyzed the performance of FilmArray gastrointestinal (GI) panel, one such multiplex PCR test, on stool specimens in patients presenting with diarrhea to our hospital from March 2016 to September 2017 and compared the results with conventional diagnostic tests.

RESULTS

A total of 106 patients were included. The panel detected at least one target in 54 out of 106 patients (50.9%) with results available on the same day. Multiple targets were detected in 26 out of 54 patients who tested positive (48.1%). Bacteria as an isolated etiology for diarrhea was present in 34 patients (62.9%), viruses (16.7%, nine patients), parasites (7.4%, four patients), and multiple pathogens in seven patients (12.9%). Enteroaggregative Escherichia coli (EAEC) was the commonest pathogen detected (in 23, 24% patients). Conventional diagnostic investigations, undertaken in 68/106 (64.1%) patients were positive in 12 (17.65%) as compared to 54/106 (50.9%) (p < 0.0001). Conventional  investigations detected a pathogen not included in the study panel in 11 of 52 patients (21.1%).

CONCLUSION

FilmArray multiplex PCR panel detects a wide array of GI pathogens including viruses and co-infections at a shorter time with more sensitivity compared to conventional diagnostics. Henceforth, it may facilitate treatment decisions, isolation policy, and antimicrobial stewardship in patients with diarrhea requiring hospitalization.

Experience with β-D-Glucan Assay in the Management of Critically ill Patients with High Risk of Invasive Candidiasis: An Observational Study

Background

The (1,3)-β-D-glucan assay (BDG) is recommended for the early diagnosis of invasive candidiasis (IC).

Methods

Records of 154 critically ill adults with suspected IC, on whom BDG was done, were analyzed. Patients were divided into three groups: Group A (confirmed IC), Group B (alternative diagnosis or cause of severe sepsis), and Group C (high candidal score and positive BDG [>80 pg/mL] but without a confirmed diagnosis of IC).

Results

Mean BDG levels were significantly higher in Group A (n = 32) as compared to Group B (n = 60) and Group C (n = 62) (448.75 ± 88.30 vs. 144.46 ± 82.49 vs. 292.90 ± 137.0 pg/mL; P < 0.001). Discontinuation of empiric antifungal therapy based on a value <80 resulted in cost savings of 14,000 INR per day per patient.

Conclusion

A BDG value of <80 pg/ml facilitates early discontinuation of empirical antifungal therapy, with considerable cost savings.

Issues in antifungal stewardship: an opportunity that should not be lost

Many countries have observed an increase in the incidence of invasive fungal infections (IFIs) over the past two decades with emergence of new risk factors and isolation of new fungal pathogens. Early diagnosis and appropriate antifungal treatment remain the cornerstones of successful outcomes. However, due to non-specific clinical presentations and limited availability of rapid diagnostic tests, in more than half of cases antifungal treatment is inappropriate. As a result, the emergence of antifungal resistance both in yeasts and mycelial fungi is becoming increasingly common. The Delhi Chapter of the Indian Association of Medical Microbiologists (IAMM-DC) organized a 1 day workshop in collaboration with BSAC on 10 December 2015 in New Delhi to design a road map towards the development of a robust antifungal stewardship programme in the context of conditions in India. The workshop aimed at developing a road map for optimizing better outcomes in patients with IFIs while minimizing unintended consequences of antifungal use, ultimately leading to reduced healthcare costs and prevention development of resistance to antifungals. The workshop was a conclave of all stakeholders, eminent experts from India and the UK, including clinical microbiologists, critical care specialists and infectious disease physicians. Various issues in managing IFIs were discussed, including epidemiology, diagnostic and therapeutic algorithms in different healthcare settings. At the end of the deliberations, a consensus opinion and key messages were formulated, outlining a step-by-step approach to tackling the growing incidence of IFIs and antifungal resistance, particularly in the Indian scenario.

Listeria in Adults - Truly Rare or Rarely Diagnosed in India?

Listeria monocytogenes is a facultative anaerobic intracellular Gram positive rod causing infection in pregnant women, extremes of age and immune-compromised hosts. In clinical specimens, the organisms may be gram-variable: laboratory misidentification of L. monocytogenes isolates as diphtheroids, streptococci, or enterococci is not uncommon and the isolation of a diphtheroid from blood or CSF should always alert the clinician to the possibility that the organism may be L. monocytogenes. The disease has rarely been reported in India in non-pregnant adults. We herein report four cases of L. monocytogenes infection in immune-compromised adults.

Multi-response optimization of Artemia hatching process using split-split-plot design based response surface methodology

A novel method, BBD-SSPD is proposed by the combination of Box-Behnken Design (BBD) and Split-Split Plot Design (SSPD) which would ensure minimum number of experimental runs, leading to economical utilization in multi- factorial experiments. The brine shrimp Artemia was tested to study the combined effects of photoperiod, temperature and salinity, each with three levels, on the hatching percentage and hatching time of their cysts. The BBD was employed to select 13 treatment combinations out of the 27 possible combinations that were grouped in an SSPD arrangement. Multiple responses were optimized simultaneously using Derringer’s desirability function. Photoperiod and temperature as well as temperature-salinity interaction were found to significantly affect the hatching percentage of Artemia, while the hatching time was significantly influenced by photoperiod and temperature, and their interaction. The optimum conditions were 23 h photoperiod, 29 °C temperature and 28 ppt salinity resulting in 96.8% hatching in 18.94 h. In order to verify the results obtained from BBD-SSPD experiment, the experiment was repeated preserving the same set up. Results of verification experiment were found to be similar to experiment originally conducted. It is expected that this method would be suitable to optimize the hatching process of animal eggs.

A Study of 24 Patients with Colistin-Resistant Gram-negative Isolates in a Tertiary Care Hospital in South India

BACKGROUND

As the use of colistin to treat carbapenem-resistant Gram-negative infections increases, colistin resistance is being increasingly reported in Indian hospitals.

MATERIALS AND METHODS

Retrospective chart review of clinical data from patients with colistin-resistant isolates (minimum inhibitory concentration >2 mcg/ml). Clinical profile, outcome, and antibiotics that were used for treatment were analyzed.

RESULTS

Twenty-four colistin-resistant isolates were reported over 18 months (January 2014-June 2015). A history of previous hospitalization within 3 months was present in all the patients. An invasive device was used in 22 (91.67%) patients. Urine was the most common source of the isolate, followed by blood and respiratory samples. Klebsiella pneumoniae constituted 87.5% of all isolates. Sixteen (66.6%) were considered to have true infection, whereas eight (33.3%) were considered to represent colonization. Susceptibility of these isolates to other drugs tested was tigecycline in 75%, chloramphenicol 62.5%, amikacin 29.17%, co-trimoxazole 12.5%, and fosfomycin (sensitive in all 4 isolates tested). Antibiotics that were used for treatment were combinations among the following antimicrobials-tigecycline, chloramphenicol, fosfomycin, amikacin, ciprofloxacin, co-trimoxazole, and sulbactam. Among eight patients who were considered to have colonization, there were no deaths. Bacteremic patients had a significantly higher risk of death compared to all nonbacteremic patients (P = 0.014).

CONCLUSIONS

Colistin resistance among Gram-negative bacteria, especially K. pneumoniae, is emerging in Indian hospitals. At least one-third of isolates represented colonization only rather than true infection and did not require treatment. Among patients with true infection, only 25% had a satisfactory outcome and survived to discharge. Fosfomycin, tigecycline, and chloramphenicol may be options for combination therapy.

Botryomycosis in a lung cavity

Botryomycosis is a rare pyogranulomatous disease characterized by suppurative and often granulomatous bacterial infection of the skin, soft tissues and viscera. Only about 90 cases have been reported in world literature till date: 75% of them are cases of cutaneous botryomycosis. Of the 18 reported cases of primary pulmonary botryomycosis, only one had histologically proven botryomycosis in a lung cavity. We report here a case of primary pulmonary botryomycosis occurring in a lung cavity, which is to the best of our knowledge first such case from India. The index case was a 62 year old female who presented to us with recurrent episodes of non-massive streaky hemoptysis with CT chest revealing 'Air Crescent' sign with a probable fungal ball in a left upper lobe cavity. Left upper pulmonary lobectomy was done and histopathology of the cavitary tissue revealed Splendore-Hoeppli phenomenon and features suggestive of Botryomycosis. Tissue culture from the cavitary specimen grew Pseudomonas aeruginosa. Botryomycosis can mimic Aspergilloma radiologically as was seen in our case, but therapy is often a combination of both medical and surgical measures unlike Aspergilloma.

Recommendations for Vaccination Against Seasonal Influenza in Adult High Risk Groups: South Asian Recommendations

Influenza is a global public health problem and concern especially in high risk people. Prevention plays a key role in avoiding complications of influenza related illnesses. Despite the existing prevalence of influenza, and documented importance of vaccination, the uptake of influenza vaccine is very poor. This document provide recommendations for influenza vaccination in high-risk individuals and help implement best practices in the South Asian region and improve coverage of influenza vaccination to achieve better outcomes in this population.

Evaluation of excess life time cancer risk due to natural radioactivity of the Lignite samples of the Nichahoma, lignite belt, North Kashmir, India

Naturally occurring radionuclides of the 226Ra, 232Th, and 40K present in the lignite samples was measured by using a low-background Pb-shielded gamma spectroscopic counting assembly utilizing NaI(Tl) detector for the measurement and to evaluation the radiation hazard indices and excess life time cancer risk. The average values of specific activity concentrations in the investigated lignite samples was found to be 45.36 Bq kg−1 for 226Ra, 21.42 Bq kg−1 for 232Th, 40.51 Bq kg−1 for 40K and 79.11 Bq kg−1 for Raeq respectively. The average value excess life time cancer risk was found to be relatively higher than the world average. Moreover, the correlation analysis shows the strong dependence of excess lifetime cancer risk on measured dose and the radium equivalent activity.

Distortion Correction of Visante Optical Coherence Tomography Cornea Images

PURPOSE

Quantitative biometry measurements from uncorrected anterior segment optical coherence tomography (AS-OCT) images are inaccurate because of spatial and optical distortions. Prior reported distortion correction equations for the Visante AS-OCT were not reproducible. The goal was to calculate the distortions and provide equations to correct corneal parameters for the Visante AS-OCT to get a central corneal radius of curvature from young and older subjects.

METHODS

Five contact lenses (CLs) of known front and back radii of curvature and central thickness were imaged using the Visante AS-OCT (Carl Zeiss, Dublin, CA). Contact lens surface coordinates from Visante images were identified and fitted with a circle using custom Matlab image analysis software. Spatial and optical distortions of the Visante image of the CL radii of curvature and thickness were calculated and corrected. Visante images were also captured from 24 younger (aged 21 to 36 years) and 30 older (aged 36 to 48 years) human subjects. Corneal radii of curvature and thickness measurements from these subjects were corrected, and intrasession and intersession repeatabilities of the corneal parameters were calculated.

RESULTS

Root mean square error of radius and power of the CL surfaces after distortion correction were 0.02 mm and 0.18D for the front and 0.011 mm and 0.11D for the back, respectively. Intraclass correlation coefficient for intrasession and intersession repeatability for all the corneal parameters from the human subjects was greater than 0.88 in both age groups.

CONCLUSIONS

A distortion correction algorithm was developed for the Visante AS-OCT and applied to extract human corneal radius of curvature measurements.

Prediction of accommodative optical response in prepresbyopic subjects using ultrasound biomicroscopy

PURPOSE

To determine whether relatively low-resolution ultrasound biomicroscopy (UBM) can be used to predict the accommodative optical response in prepresbyopic eyes as well as in a previous study of young phakic subjects, despite lower accommodative amplitudes.

SETTING

College of Optometry, University of Houston, Houston, USA.

DESIGN

Observational cross-sectional study.

METHODS

Static accommodative optical response was measured with infrared photorefraction and an autorefractor (WR-5100K) in subjects aged 36 to 46 years. A 35 MHz UBM device (Vumax, Sonomed Escalon) was used to image the left eye, while the right eye viewed accommodative stimuli. Custom-developed Matlab image-analysis software was used to perform automated analysis of UBM images to measure the ocular biometry parameters. The accommodative optical response was predicted from biometry parameters using linear regression, 95% confidence intervals (CIs), and 95% prediction intervals.

RESULTS

The study evaluated 25 subjects. Per-diopter (D) accommodative changes in anterior chamber depth (ACD), lens thickness, anterior and posterior lens radii of curvature, and anterior segment length were similar to previous values from young subjects. The standard deviations (SDs) of accommodative optical response predicted from linear regressions for UBM-measured biometry parameters were ACD, 0.15 D; lens thickness, 0.25 D; anterior lens radii of curvature, 0.09 D; posterior lens radii of curvature, 0.37 D; and anterior segment length, 0.42 D.

CONCLUSIONS

Ultrasound biomicroscopy parameters can, on average, predict accommodative optical responses with SDs of less than 0.55 D using linear regressions and 95% CIs. Ultrasound biomicroscopy can be used to visualize and quantify accommodative biometric changes and predict accommodative optical response in prepresbyopic eyes.

Objective measurement of accommodative biometric changes using ultrasound biomicroscopy

PURPOSE

To demonstrate that ultrasound biomicroscopy (UBM) can be used for objective quantitative measurements of anterior segment accommodative changes.

SETTING

College of Optometry, University of Houston, Houston, Texas, USA.

DESIGN

Prospective cross-sectional study.

METHODS

Anterior segment biometric changes in response to 0 to 6.0 diopters (D) of accommodative stimuli in 1.0 D steps were measured in eyes of human subjects aged 21 to 36 years. Imaging was performed in the left eye using a 35 MHz UBM (Vumax) and an A-scan ultrasound (A-5500) while the right eye viewed the accommodative stimuli. An automated Matlab image-analysis program was developed to measure the biometry parameters from the UBM images.

RESULTS

The UBM-measured accommodative changes in anterior chamber depth (ACD), lens thickness, anterior lens radius of curvature, posterior lens radius of curvature, and anterior segment length were statistically significantly linearly correlated with accommodative stimulus demands. Standard deviations of the UBM-measured parameters were independent of the accommodative stimulus demands (ACD: 0.0176 mm; lens thickness: 0.0294 mm; anterior lens radius of curvature: 0.3350 mm; posterior lens radius of curvature: 0.1580 mm; and anterior segment length: 0.0340 mm). The mean difference between the A-scan and UBM measurements was -0.070 mm for ACD and 0.166 mm for lens thickness.

CONCLUSIONS

Accommodating phakic eyes imaged using UBM allowed visualization of the accommodative response, and automated image analysis of the UBM images allowed reliable, objective, quantitative measurements of the accommodative intraocular biometric changes.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.

Antiretroviral Therapy for HIV Infection: Time to Switch to Once-Daily Regimens?

BACKGROUND

Data is scarce regarding virologic and immunologic outcomes and the side-effect profile of antiretroviral therapy in the private health sector in India.

METHODS

We retrospectively reviewed the case records of 250 HIV infected individuals being followed up at a private sector hospital, with emphasis on the nature of antiretroviral regimens prescribed, virologic and immunologic response to therapy and the side-effect profile of medications.

RESULTS

Once daily co-formulated tenofovir-emtricitabine-efavirenz was the most commonly used antiretroviral regimen (58% of patients). Virologic suppression (HIV RNA quantitative RT-PCR < 200 copies/ml) was achieved in 79% of patients at 6 months, 81% patients at 1 year and 87% at 5 years. The mean CD4 count at treatment initiation was 191 cells/ µl, and increased to 359 cells/µl after 1 year and to 521 cells /µl after 5 years. Stavudine was stopped in 16.7% due to side-effects, abacavir associated hypersensitivity reactions developed in 13%, zidovudine associated anemia developed in 5.2% and tenofovir was discontinued due to nephrotoxicity in 1.4%. Serum LDL, fasting blood glucose and serum creatinine did not significantly change over time in our patient population.

CONCLUSIONS

In a private sector setting, ART with co-formulated single tablet TDF/FTC/EFV resulted in excellent virologic suppression and immune reconstitution and had few adverse effects over a follow up period of almost 5 years. Nephrotoxicity was not a major concern and it may not be necessary to monitor blood glucose and lipid profiles on this regimen. Based upon our results and WHO guidelines, we recommend that the public sector ART program adopt annual virologic monitoring and switch to single pill once daily relatively non-toxic formulations as first-line regimens.

Carbapenem resistant Gram-negative bacteremia in an Indian intensive care unit: A review of the clinical profile and treatment outcome of 50 patients

BACKGROUND

Growing antimicrobial resistance and limited therapeutic options to treat carbapenem-resistant bacteremia prompted us to evaluate the clinical outcomes associated with healthcare-associated bacteremia.

METHODS

This was a retrospective observational study of carbapenem-resistant Gram-negative bacteremia performed at a tertiary care facility in Chennai, India between May 2011 and May 2012.

RESULTS

In our study, patients had mean 11.76 days of intensive care unit (ICU) care and mean time to onset of bacteremia was 6.4 days after admission. The commonest organism was Klebsiella pneumoniae (44%). Patients with combination treatment had lower mortality (44.8%) compared with colistin monotherapy (66.6%); (P = 0.35).

CONCLUSION

Carbapenem resistant bacteremia is a late onset infection in patients with antibiotic exposure in the ICU and carries a 30 days mortality of 60%; K. pneumoniae is the most common organism at our center. Two drug combinations appear to carry a lower mortality compared with monotherapy.

Melioidosis :an emerging infection in India

BACKGROUND

Melioidosis caused by the gram-negative bacterium Burkholderia pseudomallei is endemic in Southeast Asia but may be under-diagnosed and under-reported in the Indian subcontinent. This study was undertaken to analyse the clinical presentation and epidemiological risk factors for melioidosis in India.

METHODS

We carried out a retrospective study of 32 culture proven cases of melioidosis at a tertiary care hospital in South India between 2005 and 2010.

RESULTS

Thirty two culture confirmed cases of melioidosis were included in the study. Patient age varied from 4 to 60 years with a median age of 42.5 years. Males constituted 75% of cases and 78.12% of cases were from rural areas. Three-fourth (24 of 32) had at least one risk factor that predisposed to melioidosis: diabetes (43.75%) followed by alcoholism (21.87%) were the commonest. Fever was the most common symptom (68.75%) and mean duration of symptoms was 2.34 months before diagnosis. More than half of the cases (56.25%) presented as disseminated disease with the remainder having localised disease, usually septic arthritis or abscesses. Three fourth of patients (75%) were treated successfully on follow-up, with a regimen of parenteral ceftazidime followed by oral doxycycline and cotrimoxazole.

CONCLUSION

Melioidosis is an emerging infection in India especially in males from rural areas, with diabetes and alcoholism being the commonest risk factors. Both sepsis with bacteraemia and localised disease involving joints or focal abscess were common presentations. Diagnosis is readily made by culturing the organism from appropriate clinical specimens and identifying non-fermenting Gram negative bacteria to the species level. As there was an excellent response in 75% of patients, early suspicion, culture confirmation and therapy is warranted in India.

Mucormycosis in patients without cancer: a case series from A tertiary care hospital in South India

BACKGROUND

Mucormycosis (Zygomycosis) is a life-threatening infection. We attempted to analyse clinical features and risk factors of Mucormycosis cases in a tertiary care referral institution in India, in patients without underlying malignancy.

METHODS

We retrospectively analyzed data of patients diagnosed as having Mucormycosis over a 10 year period of 2000-2010. Patients with a histopathology report and/or a Microbiology report of Zygomycetes or Mucor from a biopsy specimen were included in the study.

RESULTS

Out of the 27 cases, rhino-orbital/rhino-cerebral involvement occurred in 12 (44.4%) patients, pulmonary involvement in 3 (11.1%) cases, soft tissue involvement in 11 (40.7%) cases and gastrointestinal involvement in one patient (3.7%). Diabetes mellitus is the main risk factor, followed by renal failure and trauma. Mean ESR value of these patients was 118 mm/1 hour. Mean WBC count was 20 x 10(9)/L, and neutrophil count 82%. The mean absolute neutrophil count (ANC) was 16.8 x 10(9)/L.

CONCLUSION

The interesting finding in our study was the presence of neutrophilic leucocytosis and high ESR in most of the patients. In a predisposed individual, especially in a diabetic, in countries with high environmental fungal burden; presence of high ESR and neutrophilic leucocytosis with a compatible clinical presentation should raise suspicion of Mucormycosis.

Histoplasmosis in India: truly uncommon or uncommonly recognised?

OBJECTIVES

To study the clinical profile of patients with proven histoplasmosis who had presented to a tertiary care referral centre.

METHODS

We retrospectively analysed the medical records of 24 patients diagnosed to have histoplasmosis between January 2002 and April 2011. Histoplasmosis was diagnosed when compatible intracellular organisms were seen on biopsy and/or when Histoplasma capsulatum was grown in culture.

RESULTS

Twenty four patients were diagnosed to have histoplasmosis of whom 23 were male. Diabetes and HIV infection was the most common co-morbid conditions. Subacute progressive disseminated histoplasmosis (PDH) (22 patients) was the most common clinical presentation. Ten patients had received 2-3 months of empiric anti-tuberculous therapy (ATT) with no response prior to the diagnosis of histoplasmosis. Fever, weight loss, hepato-splenomegaly, oral ulcers and lymphadenopathy were the most common clinical features. Bilateral adrenal enlargement was detected by imaging in 15 patients and adrenal insufficiency was noted in 4 patients. Itraconazole alone was used for treatment in 20 patients while 3 patients were treated with amphotericin B initially, followed by itraconazole. Response to therapy was excellent in 20 patients.

CONCLUSIONS

Histoplasmosis is an under-recognized disease in India and should be considered in the differential diagnosis of male patients with prolonged fever, adrenal enlargement, hepato-splenomegaly, oral ulcers and granulomatous disease on histopathology without response to ATT. When tissue biopsy specimens show granulomas, fungal stains should be routinely performed. Treatment with itraconazole leads to an excellent outcome in most patients.